 Well, good morning. It's always poor form to start with the resident who's supposed to do the introductions who's not here. So I'll go ahead and I'll take the pleasure of doing our introduction. So this morning we're going to have our ophthalmic pathology research fellows go ahead and give talks on some of the work that they've been doing. So Josh Hedgeko is going to give the first talk and it's the pithy title as accommodating IOLs and adjustable future. So Josh. Good morning everyone. My name is Josh Hedgeko and as Dr. Mamelis mentioned I am one of the ocular research and pathology fellows for this year. As many of you know I work very closely with Dr. Linneana Warner and Dr. Mamelis both of whom are very active in IOL research and today my talk is going to center on one of the possible and exciting futures of IOL technology which is accommodating IOLs and before I move on just a brief disclosure our lab does perform contract research with the company's PowerVision, Clarivista Medical and Schiffman Atio and this is just a quick summary slide of the intermountain ocular research center and that is headed by Drs. Warner and Mamelis. So over the past few years our lab has seen a few of these supposed accommodating IOLs. Right here the overarching design for all these IOLs is this hinge-like haptic designed to push the optic forward during accommodation. However in order for these accommodating IOLs to work there can be no or only a minimal amount of catheter fibrosis or else we end up with something that looks like this. This is an actual expanse at IOL from a human patient where the catheter fomosis is so severe that if this accommodating IOL ever worked in the past it definitely does not work now. And this is a commercially available accommodating IOL that is available with a similar problem, severe catheter fibrosis. So in the past few years our lab has been working on an accommodating IOL that does not have these problems. This is the fluid vision IOL made by the company PowerVision and this is a unique type of accommodating IOL that is actually food filled. This IOL has large haptics designed to keep the anterior and posterior capsule apart. And it is a hydrophobic acrylic lens that is actually hollow. This hollow space is filled with silicon oil that is index match to the acrylic shell around it which helps minimize internal reflections. And the theory behind this is that during accommodation fluid in the haptics moves into the optics through these specialized channels and this thus increases the curvature of the lens, the thickness of the lens and which therefore affects optical power. And this is just a brief slide illustrating the dimensions of the IOL. It has an optic diameter of 6 millimeters while the IOL entire diameter itself is 10 millimeters. This is a unique fluid filled IOL so it is no surprise that it is much thicker than a conventional standard IOL and the haptic height stands at 3 millimeters. The refractive index is 1.48 and this is a single piece IOL where the optic is suspended between the haptics. So our lab is very involved in studying these IOLs in the rabbit model. And over the past several years we have become involved in several studies with this fluid vision lens. The first one I would like to share with you is a tumor study evaluating the biocompatibility as well as the capsular pacification in a rabbit model. And just a quick pictures of a prototype version of the fluid vision lens, one from the anterior portion and one from the posterior portion of a rabbit eye. And right here I have a brief video of Dr. Ramas inserting the fluid vision IOL into the lens capsule of a rabbit eye. Right here you can see that the incision is actually quite large since this is a bulky IOL. Right here is injecting the lagging edge of the haptics and it fits into the capsule bag quite well. It does require a little bit of manipulation with the collar button hook. So this is an overview of our study. We started with six New Zealand rabbits. These are abino rabbits, which are well suited for cataract surgeries. A study lens was implanted in one eye while a control lens, which was a commercially available single-piece hydrophobic acrylic lens, was implanted in the other. Selenph examinations were taken every week between weeks one and six. And after the six weeks the rabbits were ephemeral euthanized, the eyes were enucleated and then fixed in form length. Selenph examinations were then performed in the Miyaki Appleview, where a capsule bag of pacification was scored and these gloves were then submitted for histopathology. And these are some slow-emphotos taken at the week six time point. Right here we can see a very clear anterior and posterior capsule in the fluid vision IOL, as well as a very small amount of anterior cortical proliferative material at one of the autocaptic junctions. And this is in contrast to the control IOL, where you can see a very diffuse IOL covering the visual axis. And this is some pictures from the Miyaki Appleview. So after the eyes were enucleated and fixed in form length, a sagittal cut was made at the equator region of the globe and the eye was divided into an anterior and posterior segment. And right here you're seeing the photos taken from behind the anterior segment. So right here is the backside of the fluid vision IOL and there is a capsule bag around it. And around that is the iris of the rabbit. Please keep in mind these are albino rabbits so the iris is not as pigmented as would be a human eye. Once again we see that the anterior and posterior capsules are very clear in the fluid vision IOL in contrast to the control IOL where we can see a moderate amount of PCO. And right here are some histology photos of our enucleated eyes. The eyes were processed, cut into thin sections and then viewed under a light microscope. Right here are the stained slides H and E at a 20 times magnification. Right here at the top of each photo is the cornea. Below that is iris and pupil. And right here is a markedly distended lens capsule where the fluid vision IOL resided as well as a small amount of cortical proliferative material. In the control lens over here the capsule bag is not as distended. We see a small amount of Summary's ring formation. And this kind of thick eosinic looking collection of lens epithelial cells on the posterior capsule that is consistent with the moderate PCO. And as you can see here, the control PCO is much larger than the fluid vision PCO. And those are the summary of our results from a two month study. We also did a longer term study of six months. Also value in the similar criteria of biocompatibility and capsule biocompatification. And we have some still in my photos from the four week, two month, and six month time period. Fluid vision IOL, once again very clear anterior posterior capsules all the way up to week or month six. And in the cruel IOL we see a PCO that started developing by week six that progressively became more and more diffused by six months. And as well as a very mild amount of fibrosis along the capsule eroxicus edge. Miyake Apovius pointing similar findings at the salient examination, clear capsules in the fluid vision IOL. While we can see a small amount of PCO at the optic catheter junction in the control IOL at two months, that slowly progressively became more diffused by the six month period. And some more histology slides. Very distended capsule bag in the fluid vision IOL. Small amount of proliferated cortic material. And in the control IOL, also very distended capsule bag for a very different reason. Here we see a huge amount of anterior cortical proliferated material as well as this giant PCO. And just seeing these two pictures side by side is quite remarkable because it illustrates the point that having a very distended capsule bag is effective at preventing PCO formation. And this is one of the more exciting parts of my discussion. We actually have clinical data of this fluid vision IOL in actual patients. This is a pilot study that took place with 20 patients at a single site in South Africa. Two surgeons were involved in implanting this fluid vision lens and these patients were then followed up for one year. The criteria of the study were to refine the implantation technique as well as the accommodation measurement techniques. And if the safety was demonstrated to be appropriate, the study would evolve into a multi-center clinical study involving more patients. And in the next few slides I'll show a few graphs about the results of the study. Right here we have the visual acuity measured at four different time points, months one, three, six, and 12. And overall we can see that the vision remains stable over this one year period. Right here I have two different types of accommodated measurements that the researchers used. The defocus range and the push down method. In the defocus range, accommodation is measured by using positive lenses. And over here that we can see average die after change between three and four. Die afters accommodation are retained and that was stable over the course of this one year study. In the push down method, which is basically a measurement accommodation where the patient is looking at our chart, the slowly moves away from them. We see stable accommodation over the entire study between around 2.5 to three die afters. Of note these are both subject to studies that are very dependent on the patient to provide whether the accommodation was accurate. And in this next measurement accommodation this is an objective study. Right here polycarpene was induced accommodation by constricting the cellar muscle and forcing accommodation. So machine was able to measure the accommodation before administration of the polycarpene and after. And right here we see about 2.5 to three die afters of accommodation over the course of this 12 month study. And all patients ended up responding with some sort of lens power increase. So since this is a fluid filled IOL you may wonder if contrast sensitivity is on par for maybe some commercially available IOLs right now. The researchers compared this fluid vision IOL with the cushion available monofocal lens, specifically the technus lens, as well as three common and popular multifocal lenses. And then we can see that the fluid vision IOL is comparable in contrast sensitivity to the monofocal lens and is superior to that of the multifocal lenses in both mesopic and mesopic ocular conditions. So in summary, this pilot study that involved a fluid filled IOL revealed a stable visual acuity and significant accommodation after 12 months. The researchers decided it was safe to expand on the study and there's currently a larger study going on right now in South African Germany. Just a heads up not to hold your breath. Probably not gonna see this in US for many years, if ever. And before I move on to my final lens I wanted to quickly introduce or reintroduce the Harmony Modular IOL made by Clare Vista Medical. If you remember Dr. Mamelis presenting this briefly at Clinical Translation Research Day. This is a hydrophobic acrylic multi-component lens where a base is fixated into the capsule or bag that serves as a docking station for the optic. The optic is designed to be easily removed and adjusted without manipulation of the capsules. And so far a lab has been involved in a couple of these studies that we so far have published. And just a quick overview of the results of the study. The Harmony lens exhibited appropriate UVO biocompatibility as well as less capsular bag of pacification than the standard control IOL. And right here we can see just significantly more PCO in both the control lenses, these pictures over here, compared to the fluid vision or not the fluid vision, the Harmony lenses. And right here we see absence of PCO in the Harmony lens as opposed to a very obvious PCO in the control. And of note, this is a textbook photo of Summary's ring formation and this dumbbell formation right here. These large two eosinophilic bodies along the periphery of the lens capsule. So so far I discussed a modular type IOL as well as a fluid-filled accommodating IOL. So what would happen if you combine these two concepts into one? And that is exactly what Atia Schiffma did with their fluid-filled accommodating modular and adjustable IOL. This lens has two components, a flexible hydrophilic acrylic base that is filled with silicon oil, as well as a thin hydrophilic acrylic optic. The base is fixated within the casserole bag and the optic is clipped to the base. And the theory is upon accommodation the silicon oil flows from the haptic into the center of the base which then pushes the optic forward. So this is another video of Dr. Manlis inserting the lens into the eye. This is the first part of the lens insertion which is the base. It is quite bulky so he's pushing it deep into the lens casserole bag while slowly withdrawing on the injector. And right here you can see it's slowly unfolding nicely into the bag and there just pops out. It's quite flush in there which is nice. The next part of this video shows Dr. Manlis inserting the optic which has a hinge part that is designed to slip into the base itself. A lot of these times the optic becomes very flush with the base with very minimal manipulation. But right here we can see that a small part of the optic is sticking up requiring a little bit of manipulation with the collar button hook. And then it just slides in quite nicely right there. So it is still very early in this lens because we're still going through rapid studies in vivo studies but we do have some preliminary results from our lab so far. These atio-io-wells have shown appropriate UVO biocompatibility as well as less casserole bag classification than a standard IOL. The space between the base and the optic is not connected to the casserole bag and we have seen no signs of any inter-lenticular opacification. So in summary this field of accommodating and modular-adjustable IOLs is a very promising research area. Almost every one of us will develop cataracts as well as presbyopia sometime in our life and it would be very nice to have an IOL that addresses both of these issues. Challenges still remain in the terms of casserole bag opacification as well as casserole bag sizing and since these are still quite bulky lenses we gotta figure out a way to make these incisions a little bit smaller. And that is my presentation and thank you very much for your time.